The Eustachian tube is a narrow tube-like passageway that connects the thimble-sized space behind the eardrum (the middle ear) to the space behind the nose. Its purpose is to provide a way for air to move in or out of the middle ear so that the air pressure in the ear is always equal to the air pressure around us, even with changes in external air pressure.

When the Eustachian tube is working perfectly, it is closed and opens only very briefly when we swallow or yawn. There is a pulley-like muscle above the roof of our mouth that pulls it open when we swallow or yawn. Some people can actually hear a “crackling” sound every time this happens. Others hear it only sometimes, while some never hear it. Almost everyone becomes aware of this air movement when their ears finally “pop” during altitude changes such as during airplane flights or while ascending or descending a mountain or high elevator shaft. During these altitude changes, before the Eustachian tube opens to equalize the pressure, one can experience pain in the ear because the difference in air pressure on each side of the eardrum actually stretches the eardrum, which is quite sensitive.

The Eustachian tube works well for most people most of the time. Its diameter is only about as big as a pencil lead, so its surprising it works as well as it does. However, there are two very common Eustachian tube problems that can cause ear symptoms. One is when the Eustachian tube remains in the open position. The other is when the Eustachian tube fails to open with swallowing. Oddly, BOTH of these problems cause the ear to feel stopped up. Sometimes its difficult to sort out which of these two problems is causing the symptom.

The Eustachian tube can fail to open due to a virus, cold, allergy, sinus infection, scar tissue, or sometimes for no particular identifiable reason. Fortunately, it usually eventually returns to normal function without any treatment, but it can sometimes last for a very long time. If it stays completely closed for long enough, the air behind the eardrum in the middle ear can eventually be absorbed by the lining of the middle ear. This can create enough vacuum to cause the ear lining to produce a mucus-like fluid that fills the middle ear space. When this happens, one will experience hearing loss similar to that produced by putting an earplug in the ear. Even this will frequently resolve without treatment. If it does not, your doctor can suggest treatment.

The opposite problem, a Eustachian tube that stays in the open position, is called a “Patulous Eustachian Tube”. It can be caused by weight loss, by hormonal changes from pregnancy, menopause, pre-menopause, hormone medication, or for no identifiable reason. Most of the time no specific cause is identified. Even though this makes the ear feel “full” or “stopped up”, the hearing stays normal. The full feeling is bothersome, but it does not cause pain and it is no threat to your ear. Fortunately, this will usually go away by itself. Unfortunately, treatment of this benign but bothersome condition is very limited. We physicians are better at explaining the “patulous Eustachian tube” and ruling out more serious ear conditions than we are at curing it. The body is good at eventually recalibrating the opening and closing of the Eustachian tube, but your doctor cannot predict how long this will take. Sometimes, for reasons that are hard to explain, making a small opening in the eardrum and placing a tube to keep it open can help. On the other hand, sometimes this procedure can actually make the symptom worse. This procedure is usually reserved for patients who have symptoms that do not resolve on their own after a very long time.

Mark Brown, MD.